Guidelines for Medication Administration In Kansas Schools

Transcription

1 Guidelines for Medication Administration In Kansas Schools Guidelines for Medication Administration In Kansas Schools Revised June 2010 Bureau of Family Health, Children and Families Section

2 Guidelines for Medication Administration in Kansas Schools, 2010 are a revision of the Guidelines for Medication Administration in Kansas Schools, 2001.

3 June 23, 2010 Dear Colleagues: In November 2001, Guidelines for Medication Administration in Kansas Schools was published by the Kansas Department of Health and Environment as a resource for school nurses and administrators to safely administer medication to children attending Kansas schools. The original 7-page document assisted schools in developing policies and procedures mindful of the multidisciplinary laws and regulations from Boards of Nursing and Pharmacy. Although it was a valuable resource, increasing complexity of treatment modalities and expanding opportunities for student participation in a variety of school settings necessitated a revision and expansion. This revision, 2010 Guidelines for Medication Administration in Kansas Schools, expands the framework of the original document and includes a variety of new resources. It provides more comprehensive, clear and thorough information on topics such as training of unlicensed school personnel, use of student-specific emergency medication, medication administration outside of regular attendance hours, storage, inventory and disposal of medication, as well as planning for provision of student medication in an emergency building evacuation. The appendices provide resources that include delegation resources, sample documents, and statutes specific to the use of emergency medications. Registered nurses from school districts and public health departments, as well as representatives from the state boards of nursing and pharmacy, have contributed to the content of this document. The final product reflects the multidisciplinary partnerships required both at the state and local levels to assure safe medication management and administration to students in our schools. Thank you all for the good work you do to safeguard the health of Kansas school children. Please let us know if you find these materials helpful, or if there are other topics that would be helpful to include in this document in the future. We look forward to hearing from you. Sincerely, Jason Eberhart-Phillips, MD, MPH Kansas State Health Officer and Director of Health, KDHE

4 TABLE OF CONTENTS I. Acknowledgements...5 II. Introduction to Guidelines for Medication Administration in Kansas Schools...7 III. The Kansas Nurse Practice Act, Regulations for Performance of Selected Nursing Procedures in the School Setting, and Protection of the Public...8 IV. Training Unlicensed School Personnel...10 V. Medication Administration Guidelines...12 A. Medications in the School Setting...13 B. Parent / Legal Guardian Request and Permission...13 C. Prescription Medication...14 D. Nonprescription or Over-the-Counter (OTC) Medication and Other Homeopathic Remedies...14 E. Verbal Medication Orders...16 F. Five Rights of Administering Medication...16 G. Medication Documentation...16 H. Changes to Medication Once Prescribed...17 I. Use of Unit Doses and Blister Packs...17 J. Use of Student Specific Emergency Medication in the School Setting...17 K. Self-administration of Student Specific Emergency Medication...18 L. Medication Administration Outside of Regular Attendance Hours by School Personnel...19 M. Storage of Medication...19 N. Inventory of Medications...19 O. Medication Errors...20 P. Disposal of Medications...20 Q. Disposal of Needles and Syringes...21 R. Emergency Building Evacuation and Medications...21 S. Field Trips...21 T. Poison Control Center U. Research Medications in the School Setting...22 VI. Stock Epinephrine in the School Setting for Treatment of Undiagnosed Severe Allergic Reactions / Anaphylaxis by School Personnel

5 VII. Appendix...25 A. Delegation of Specific Nursing Tasks in the School Setting for Kansas Grid...26 B. Sample Documentation of Instruction from the Licensed Professional Registered Nurse to Unlicensed Assistive Personnel...28 C. Sample Authorization for Medication / Procedure to be Administered at School & Field Trips...30 D. Samples Documentation of Medication Administration Forms...32 E. Statute K.S.A Policies to allow student to self-administer certain medications F. Sample Authorization for Self Medication: Emergency Asthma/Allergy Medications...37 G. Sample Controlled Substance Log...39 H. Suggested Procedures for Medication Errors and Sample Medication Error / Occurrence Report Form...41 I. Sample Medication Count Log...46 J. Statutes Pertaining to Epinephrine Kits...48 a. K.S.A Epinephrine kits; requirements. b. K.S.A Epinephrine kits in schools; rules and regulations. c. K.S.A b Same; administration of epinephrine; limitation of liability. K. Kansas State Board of Nursing Ruling: The use of Epinephrine to treat life-threatening emergencies in children not previously diagnosed. June L. Five Rights of Medication Administration in the School Setting M. Samples School Board Medication Policy

6 I. ACKNOWLEDGEMENTS The following individuals have contributed to the content and/or review of the manual. The assistance of these professionals is greatly appreciated and has enhanced the usefulness of this manual for practitioners working with Kansas s children. Katrina Benyshek, RN, BSN, NCSN Director of Health Services, Ulysses, KS USD 214 Debra Billingsley, Executive Director Kansas State Board of Pharmacy Dennis Cooley, MD, FAAP Kansas Chapter, American Academy of Pediatrics (KAAP) Eileen Filbert, RN, Adm.C. Jefferson County Health Department, Home Health & Hospice Cindy Galemore, RN, MS Director of Health Services, Olathe USD 233 Diane Glynn, JD, RN Practice Specialist Kansas State Board of Nursing Jane Norris, RN, BSN, CSN Nurse Coordinator Coordinated School Health Program Coordinator USD 353 Carole A. Prather MS, ARNP, BC Family Nurse Practitioner, Center for Child Health & Development University of Kansas Medical Center Christine Tuck, RN, MS, NCSN Director of Health Services, Seaman USD 345 Pam Shaw, MD, FAAP Vice Chair of Education, University of Kansas Medical Center Dept. of Pediatrics Kansas Chapter, American Academy of Pediatrics (KAAP) 5

7 KDHE Reviewers: Jason Eberhart-Phillips, MD, MPH Kansas State Health Officer Linda Kenney, MPH Director Bureau of Family Health Ileen Meyer, RN, MS Director Children and Families Section Jane Stueve, RN, BSN Adolescent and School Health Consultant Children and Families Section Manual Revision Coordinator Brenda J. Nickel, RN, BSN Child and School Health Consultant Children and Families Section Editors Carrie Akin Administrative Specialist Children and Families Section Penny Hulse Senior Administrative Assistant Children and Families Section 6

8 II. INTRODUCTION TO GUIDELINES FOR MEDICATION ADMINISTRATION IN KANSAS SCHOOLS Rationale Children with acute and chronic illnesses may require medication during the school day. School districts must meet this need in the interest of facilitating school attendance and to comply with applicable state and federal laws. Many children and adolescents are able to attend school because of the effectiveness of their medications. The health circumstances requiring medication are diverse. Medication may be essential for continued functioning, either as a component of an elaborate treatment plan for the student with a complex disability or as the only treatment necessary for a student to maintain or regain control of his/her chronic illness. In some instances medications may be necessary for life-threatening emergencies. For most students, the use of medication will be a convenient benefit to control acute minor or major illnesses, allowing a timely return to the classroom with minimal interference to the student and to others. A student may also symptomatically benefit from nonprescription (over-the counter, or OTC) medications, natural, or homeopathic remedies. The National Association of School Nurses (NASN) provides an overview of the use of medication in the school setting in a position statement, Medication Administration in the School Setting at School districts must establish policies and implement procedures that meet all legal requirements for administration of medication required during school hours. The procedures must be consistent with standards of medical, nursing, and pharmacy practice guidelines. The school board and the school superintendent, in conjunction with school or public health nurses, other school personnel, a physician or pharmacy consultant and health advisory committee for each school (district), should develop a policy for the safe administration of medication in the school setting. As policies and guidelines are developed and implemented, school administrators and licensed health professionals must be aware of Kansas legal requirements and constraints related to who can legally administer medications in schools. Assuring the safety of the child (including immediate access to life-sustaining medications, e.g., epinephrine for severe allergic reactions, or rectal anticonvulsant medication for severe seizures) and the legal rights of school personnel who dispense medications must be considered, as well as the need for children to take ever-increasing responsibility for their own health. The Kansas Department of Health and Environment (KDHE), recommends that advice of knowledgeable school nurses, physician consultants and legal counsel experienced in school health be sought as these policies, procedures, and monitoring guidelines are determined at the local level with consideration of state statutes and regulations. 7

9 Considerations The administration of prescription medications is considered a registered professional nursing task and/or procedure per the Kansas Nurse Practice Act (K.A.R through ). Therefore, school districts must employ or contract with registered professional nurses to assume responsibility for implementing a system of safe administration of medication. This system may include delegation of medication administration to unlicensed assistive personnel in the absence of a full-time on-site nurse, including during field trips, and before or after school events. Issues the school nurse confronts related to the administration of medications according to the National Association of School Nurses Position Statement Medication Administration in the School Setting can be found at: More specifically, the use of delegation is interpreted to mean that the nurse: Determines who can safely and competently perform this task; Assesses any learning needs of the individual; Provides a standardized training in the procedure; Periodically monitors and supervises the individual performing the task to determine that the individual is following correct procedure; Determines the extent of the supervision needed; Periodically repeats the instruction; Is available for consultation regarding the procedure; and Ensures access to medication in the absence of the nurse. In the absence of a school district employing a registered professional nurse, only the primary care provider or specialist may supervise or delegate administration of medication in the school setting. Schools are strongly encouraged to pursue all educational and behavioral alternatives aimed at problem resolution without prescription and nonprescription medication if at all possible. III. THE KANSAS NURSE PRACTICE ACT, REGULATIONS FOR PERFORMANCE OF SELECTED NURSING PROCEDURES IN THE SCHOOL SETTING, AND PROTECTION OF THE PUBLIC The Kansas Board of Nursing (KSBN) is the regulatory agency charged with protection of the public health, safety and welfare of the citizens of Kansas through the licensure and regulation of nursing practice. The Kansas Nurse Practice Act (NPA) is the legal document regulating the practice of every licensed registered professional nurse (RN) and licensed practical nurse (LPN) in the state of Kansas. The NPA dictates the scope of practice for all professions regulated by the KSBN, regardless of practice setting and has the ultimate legal authority to interpret these laws 8

10 relating to the practice of nursing The Kansas NPA can be viewed, downloaded and printed at The following Kansas Administrative Regulations (K.A.R through ) of the NPA specifically address Performance of Selected Nursing Procedures in the School Setting and must be considered when creating health policies for local school districts. K.A.R Definitions and Functions: Only a licensed registered professional nurse (or a physician provider) has the authority to delegate the administration of medication or other nursing procedures in schools to unlicensed assistive personnel (UAP) and only with appropriate and adequate training, supervision and performance evaluation of the UAP as referenced in K.A.R This regulation can be accessed at K.A.R Delegation Procedures: Nursing procedures (including medication administration) in the schools can only be delegated by a licensed registered professional nurse in accordance with K.A.R This includes a nursing assessment of the student and the development of a plan of care for the student that may include delegation to an UAP. This regulation can be accessed at An additional tool to assist with delegation procedures is the Delegation of Specific Nursing Tasks in the School Setting for Kansas Grid approved by the KSBN, September 15, The table is to be used to determine to whom specialized caretaking tasks or procedures may be delegated. Only the licensed professional registered nurse responsible for the student s nursing care may determine which nursing tasks may be delegated to an UAP (See Appendix A: Delegation of Specific Nursing Tasks in the School Setting for Kansas Grid). K.A.R Supervision of Delegated Tasks or Procedures: The supervision of delegated nursing procedures in the school setting, including medication administration, must be done in accordance with K.A.R This includes the licensed registered professional nurses responsibility for determining the degree of supervision required based on the health status and stability of the student receiving nursing care, the complexity of the task or procedure to be delegated to the UAP, the competency and training of the UAP to whom the task is delegated, and the proximity of the supervising licensed registered professional nurse to the student and UAP. (See Appendix B sample form: Documentation of Instruction and Supervision from the Registered Nurse (RN) to Unlicensed Assistive Personnel (UAP) in the School.) This regulation can be accessed at 9

11 K.A.R Medication Administration in the School Setting: If the requirements of K.A.R through have been met, the licensed registered professional nurse may delegate medication administration to a UAP if: o No dosage calculation is required and; o The medication is administered by accepted methods specified in the nursing plan of care. o A registered professional nurse shall not delegate the procedure of medication administration in a school setting to unlicensed persons when administered by any of these means: By intravenous (IV) route; By intramuscular (IM) route, except when administered in an anticipated health crisis; Through intermittent positive-pressure breathing machines; or Through an established feeding tube that is not inserted directly into the abdomen. This regulation can be accessed at Because new medications and procedures with implications for licensed professional registered nurse practicing in school settings are constantly being approved and introduced, school nurses and administrators are encouraged to seek interpretation from the KSBN if questions arise. Specific practice questions regarding performance and delegation of nursing procedures, including medication administration in the school setting should be directed to Diane Glynn, JD, RN, Practice Specialist, or [email protected]. IV. TRAINING UNLICENSED SCHOOL PERSONNEL The registered nurse is responsible for training unlicensed school personnel in basic knowledge of safe medication administration in the school setting. The methods of administration to be delegated should be determined by the school nurse, described in school board policy, and may be personnel-specific (See Appendix B: Sample Documentation of Instruction from the Licensed Professional Registered Nurse to Unlicensed Assistive Personnel.) Individuals delegated for and trained to administer medication should be able to: Describe their roles in the delivery of medications; State the general purpose of medication administration; List any needed equipment and supplies; 10

12 Demonstrate proper administration of oral, topical, eye, ear, inhalant, and emergency medications, including proper hand washing; Demonstrate appropriate and accurate documentation of medication administration; Demonstrate appropriate action if unusual circumstances occur, i.e., medication error, adverse reaction, student refusal, etc; and Know how and when to seek consultation from the supervising nurse. The following are suggested roles for school personnel related to the delegation and training of unlicensed school personnel for medication administration: 1. School Administrator a. Assist in development of medication administration policy and procedures and seek school board support for policy. b. Provide administrative support for compliance with district medication administration procedures; c. Assist nurse in educating staff and parent(s)/legal guardian(s) about the district s commitment to a safe policy related to medications in school; and d. Be aware of liability issues related to medication administration at school, including insurance coverage, personnel covered, etc. 2. Registered Professional Nurse a. Understand recommended updates and revisions, and continually evaluate district policy and procedures related to medication administration; b. Determine who can safely provide medication administration; c. Provide guidance for special circumstances, i.e., field trips, verbal orders, etc.; d. Provide a standardized training course for all personnel who will administer medications; e. Maintain a record of training, including course attendance, written tests, and performance evaluations demonstrating 100 percent mastery of course content; f. Periodically monitor performance through observation of procedures, review of documentation, handling of medications, etc., (at least yearly); g. Provide medication information resources and update as needed; h. Encourage open communication with individuals delegated to administer medication; i. Review and take appropriate action regarding any reported medication error j. Take corrective action when individual to whom medication administration is delegated does not meet standard performance after consultation and retraining; k. Develop an educational program for all students regarding the appropriate use of medications, including the resolution of minor health problems without the use of medication; and l. Share policies, procedures, and forms with local authorized prescribers. 11

13 3. Unlicensed School Personnel a. Participate in district training related to medication policy and procedures: b. Administer medications strictly following the procedure as taught; c. Provide accurate documentation of medications administered; d. Call for consultation with delegating nurse when there is any question, or when a parent/legal guardian does not comply with policy; and e. Provide safe storage and handling of medications as outlined in district policy. 4. Parent(s)/Legal Guardian(s) a. Cooperate with the district s policy regarding medication administration to: b. Provide authorization or prescription from student s health care provider; c. Provide written request from parent/legal guardian to administer medication; d. Provide the school with the medication as outlined in the policy; e. Communicate any changes in student s health status, medication regime, change of health care provider, etc.; and f. Sign authorization for school to communicate with student s health care provider if needed. 5. All School Personnel a. Understand and follow school district policy and procedures related to medications; and b. Understand and follow school district policy regarding self-administration of medications. 6. Prescriber a. Write a complete order including name of medication, dosage, time, frequency, and length of treatment; and b. Collaborate and communicate medication instructions and pertinent information to the parent/legal guardian, student, and school staff, as necessary. V. MEDICATION ADMINISTRATION GUIDELINES The following state guidelines have been developed and endorsed by the KDHE, the Kansas School Nurse Organization, the Kansas Maternal and Child Health Council, and the Kansas State Board of Pharmacy. Representatives from the KSBN, the Kansas State Nurses Association, the United School Administrators, the Kansas Association of School Boards, and the Kansas State Department of Education have reviewed and provided input for these revisions. These guidelines do not supercede or supplant the Kansas Administrative Regulations (K.A.R through ) referenced herein. These guidelines are not legally binding upon 12

14 local boards of education as are the regulations. Rather these guidelines provide more in-depth information to assist the local boards of education in complying with the regulations. A. Medications in the School Setting Per K.A.R , licensed professional registered nurses are responsible for the management, administration, and delegation of all medications in Kansas schools. If a licensed professional registered nurse is not on staff, only the primary care provider or specialist M.D. (Doctor of Medicine and Surgery), D.O. (Doctor of Osteopathic Medicine), D.D.S. (Doctor of Dental Surgery), A.R.N.P. (Advanced Registered Nurse Practitioner), P.A. (Physician s Assistant), or O.D. (Optometrist) for certain eye medications may supervise or delegate administration of medications in schools. It is assumed that medication will be administered during the school day only when the interval between doses requires administration in school or the medication is a "when necessary" order. Only oral, prescribed subcutaneous, topical or intranasal medications, eye or ear drops should be routinely administered at school. Medications requiring IV or IM routes must without fail be accompanied by a detailed Individualized Healthcare Plan (IHP) developed by the licensed professional registered nurse in collaboration with the prescribing primary care provider or specialist. The licensed professional registered nurse, because of educational background and knowledge, is uniquely qualified to monitor and administer medication for children and adolescents. B. Parent / Legal Guardian Request and Permission A written request from the parent/legal guardian must accompany all prescription, OTC medications, and natural and homeopathic remedies to be administered (See Appendix C sample form: Authorization for Medication / Procedure to be Administered at School and Field Trips). The written request and primary care provider or specialist medication orders must be updated annually and include: a. Student name and birth date b. Date of parent/legal guardian request c. Reason the medication is prescribed d. Parent/legal guardian understanding of school policies regarding medication administration, including OTC and natural/homeopathic remedies e. Authorization for the designated school personnel or licensed professional registered nurse to communicate with the prescribing primary care provider or specialist to ensure continuity of care f. Parent/legal guardian signature g. Primary care provider or specialist signature 13

15 C. Prescription Medication Written authorization from a primary care provider or specialist (M.D., D.O., D.D.S., A.R.N.P. or P.A.) must accompany any prescription medication to be administered at school. An Optometrist (O.D.) may prescribe certain topical medications for the eyes. The authorization form must be dated and include: a. Student name and birth date b. Medication c. Dosage d. Route of administration e. Reason the medication is prescribed f. Time(s) to be administered g. Duration of administration, i.e. entire year, 5 days, 1 month, etc. Prescription medication must be brought to school in a container/package dispensed by the pharmacist with the following information clearly stated on the label: a. Name of student b. Medication c. Dosage d. Route of administration e. Reason the medication is prescribed f. Time(s) to be administered g. Duration of administration, i.e. entire year, 5 days, 1 month, etc. D. Nonprescription or Over-the-Counter (OTC) Medication and Other Homeopathic Remedies It is recommended that written authorization from a primary care provider or specialist accompany nonprescription over-the-counter (OTC) medications, natural and homeopathic remedies, as well as prescription medications, in order to ensure continuity of care and to prevent unintended medication interactions. OTC medications have therapeutic benefits, as well as risk of potential side effects, and carry the potential for great harm if misused or abused. At the same time it is understood that students may symptomatically benefit from appropriate use of OTC medications and that their use may facilitate a student s return to class and remove temporary barriers to learning. Some primary care providers or specialists may determine that the use of nonprescription medications is a parental/legal guardian decision and not a physician decision, and may be unwilling to authorize OTC medications in the schools since they have no control over which medications are actually purchased for use. Consequently, it may sometimes 14

16 be in the best interest of the student for the licensed professional registered nurse to administer OTC medications in the original container with standardized, age/weightappropriate dosing information at parent/legal guardian request, for a specific timelimited minor illness (e.g. cough drops, for colds, Ibuprofen for muscle strain) or for intermittent conditions (e.g. Acetaminophen or non-steroidal anti-inflammatory drugs for menstrual cramps, hydrocortisone ointment for insect bites, etc). A written request signed by the parent/legal guardian must accompany the medication and include: a. The name of the medication b. The medication dose c. The time for administration of the medication d. The reason for the medication e. A statement relieving the school of any responsibility for the benefits or consequences of the medication when it is parent/legal guardian prescribed and acknowledging that the school bears no responsibility for ensuring the medication is administered except when the student requests the medication. In this instance, documentation of medication administration by the licensed professional registered nurse or UAP delegated to administer OTC medication when requested must be completed. f. OTC medication must be brought to school in the original manufacturer container/package with all labels intact. Deviations from label directions will require a written provider order. g. The school should retain the request for at least as long as the medication is used at school. It is preferable that the request remains part of the student s permanent health record. The school must reserve the right to limit the duration of parent/legal guardian prescribed medications and to require primary care provider or specialist authorization for continued use. Because the formulation of herbal, natural and homeopathic remedies is unregulated, their potential for harm is great in a school setting where a student s complete medical history and medication history may not be known. These medications/remedies should not be administered at school without primary care provider or specialist authorization. Even with proper authorization, the school must take into consideration the risk inherent to student safety in administering a product that lacks published data about its safety, efficacy, and dosages for children. A position statement from the National Association of School Nurses (NASN) called Alternative Medicine Use in the School Setting can be found at 15

17 E. Verbal Medication Orders The licensed professional registered nurse may take a verbal medication authorization from a primary care provider or specialist for prescription medication or a parent/legal guardian for OTC medication so long as the verbal authorization is followed the next working day with a written authorization. Such authorization may be faxed to the school with appropriate confidentiality safeguards in place. UAPs should not under any circumstances take verbal orders from primary provider or parents/legal guardians. F. Five Rights of Administering Medication Medication errors will be controlled by checking the following 5 items each time medication is given (AAP, 2005, p. 494). (For more detailed explanation, see Appendix L: Five Rights of Medication Administration in the School Setting.) The right child / student The right medication / drug The right dose The right time The right route of administration G. Medication Documentation An individual record (log) must be kept of each medication administered to each student. The record must identify (See Appendix D sample forms: Documentation of Medication Administration): a. Student by name and birth date b. Allergies c. Prescribing primary care provider or specialist name and credentials d. Medication e. Route of administration f. Time of administration g. Duration of administration h. Potential side effects i. Initial nursing assessment j. Signature of licensed professional registered nurse responsible for administration k. Signature of unlicensed assistive personnel (UAP), if administration is delegated l. Section for comments and narrative notes 16

18 H. Changes to Medication Once Prescribed Any changes in medication, including dosage and/or time of administration must be accompanied by: a. New primary care provider or specialist and parent/legal guardian authorization forms with signatures b. New container/package appropriately labeled by the pharmacist c. An additional assessment provided by the licensed professional registered nurse when any change in medication, including dosage and/or time, is made. It is essential that the licensed professional registered nurse or delegated UAP be able to unequivocally match the student name, medication, dosage, administration time and route to the student s medication record to avoid medication errors. I. Use of Unit Doses and Blister Packs The use of unit dose or blister pack packaging should be encouraged in the effort to safeguard student health and avoid medication errors. If unit dose packaging is not available, two separate prescription containers should be requested from the prescribing provider and pharmacist one for school and one for home. Medications brought to school in plastic bags, envelopes, lunch boxes, etc., should not be administered, regardless of whether they are labeled or not. J. Use of Student Specific Emergency Medication in the School Setting Children with diagnosed chronic health conditions such as seizure disorders, diabetes, asthma and severe allergic reactions, may have medication prescribed to treat a medical emergency. An Anticipated Crisis Plan must be developed for students whose conditions may warrant intervention with medication such as glucagon for unconsciousness due to hypoglycemia (low blood sugar), anticonvulsant medication to be administered rectally for a protracted seizure, and epinephrine for a severe allergic reaction (anaphylaxis). The licensed professional registered nurse or prescribing primary care provider or specialist is responsible for training school staff in the recognition of life-threatening emergencies and the appropriate administration of emergency medications. Resources to assist in development of Anticipated Crisis Plans and use of emergency medication can be found at the following websites: NASN, The Role of School Nurses in Allergy/Anaphylaxis Management 17

19 NASN, The Role of the School Nurse Caring for a Student Requiring a Rectal Medication for Seizures KDHE, Guidelines for Nursing Management of Students with Chronic Disease or Health Conditions in School Settings KDHE, Guidelines for Serving Students with Special Health Care Needs Part 2 K. Self-administration of Student Specific Emergency Medication Primary care providers or specialists recognize the need for students with special health care needs requiring medications and technology to assume more responsibility for their own health care. As a result, providers are requesting that students be granted the autonomy to self-administer some medications in the school setting. It is the recommendation of the KDHE, the American Academy of Pediatrics, and the NASN that the licensed professional registered nurse monitor the self-administration of certain medications (i.e. epinephrine, insulin, multi-dose inhalers) by students who demonstrate the capability for responsible self-administration (See Appendix F sample form: Authorization for Self Medication: Emergency Asthma/Allergy Medications.) In 2005, the Kansas legislature passed a law (K.S.A ) allowing students to selfadminister certain medications. (See Appendix E.) Each school district shall adopt a policy authorizing the self-administration of medication by students enrolled in kindergarten or any of the grades 1 through 12. A student shall meet all requirements of a policy adopted pursuant to this subsection. The statute and the requirements for selfadministration of certain medications can be found at A detailed Individualized Health Care Plan ensuring adequate and appropriate communication with the school nurse and appropriate written authorizations from both the health care provider (MD, DO, ARNP, PA, DDS, OD) and the parent/legal guardian should be in place before self administration of medications is permitted. Regular monitoring and evaluation of self-administered medications must be the responsibility of the licensed registered professional nurse and should not be delegated. The school should reserve the right to discontinue self-administration of medications if the privilege is abused or the safety of other students is compromised. The self-administration of controlled substances should never be permitted in the school setting. 18

20 L. Medication Administration Outside of Regular Attendance Hours by School Personnel Medications used after school in athletic areas by coaches or trainers or by sponsors of other school activities outside of regular school attendance hours when medication administration / documentation has been appropriately delegated, including OTC medications, are subject to the same requirements for authorization, storage, and administration as any other medication in the school setting and should not be maintained on or off school premises without these safeguards. (l) Extended program hours means any program that occurs before or after school attendance hours and is hosted or controlled by the school. For more information consult K.A.R Definitions and functions. M. Storage of Medication All medications (including OTC medications) maintained in the school setting (other than those approved for self-administration by specific students) must be kept in a locked and secured container or cabinet, in a room that can be locked. Medications requiring refrigeration should be kept in a secured refrigerator inaccessible to students or staff and should never be stored with food. Access to medications must be limited and it is recommended that a list of persons with access to medications be maintained and updated regularly. N. Inventory of Medications Medications must be inventoried at least every semester by a licensed health professional and another staff member. Expired medications must be destroyed or disposed of and their disposition clearly documented. (See Appendix G sample form: Controlled Substance Log.) Medications no longer being used should be returned home or destroyed. Needles, syringes, lancets, etc. should be sealed in a puncture proof container and properly disposed of. Controlled substances must be counted when received and an accounting made at least weekly of remaining totals by the school nurse and an observer. All counts must be clearly documented on the student medication record and initialed by the participants. This process is greatly facilitated by the use of unit dose packaging or blister packs. Ideally, no more than a 30 day supply of prescribed medication should ever be stored at the school. 19

21 O. Medication Errors A medication error is a deviation from the standard of care for a client concerning correct medication delivery and includes all of the following: Omitted doses, incorrect doses, incorrect time of administration, incorrect client, improper injection techniques, and incorrect route of administration (Schwab & Gelfman, 2001, p. 617). It is important to establish processes and train and monitor people to prevent medication errors... Nonpunitive reporting will facilitate obtaining support for system enhancements... (Johnson, Hayes, Reinstein, Simmons, & Benson, 2003, p. 52). School districts are encouraged to have medication error reporting addressed by a school district risk management policy, through the use of a medication incident reporting form and the specification of persons to be notified, including the licensed prescriber if there is a question of potential harm to the student (Schwab & Gelfman, 2001). For example, if medication administration has been delegated, the licensed professional registered nurse supervising the UAP must be notified immediately and assume responsibility for notifying parents/legal guardians, the building administrator, and the coordinator of school health services. A school district incident form should be filed in the student health record and with the prescribing provider (See Appendix H sample form: Medication Error / Occurrence Report Form and Suggested Procedures for Medication Errors.) The employee completing the medication incident report is encouraged only to state the facts of what occurred, avoiding use of terms suggestive of an error, such as accidently or by mistake. References to district problems should also be avoided in the documentation, e.g. staff shortages. The licensed professional registered nurse may reasonably work within a timeframe or window of minutes of the prescribed time for medication administration based on priorities and nursing judgment without creating an error of omission. Any window of time granted to UAPs to whom medication administration has been delegated should be clearly documented in the delegation plan of care by the supervising licensed professional registered nurse. P. Disposal of Medications Medications that are out of date or have been discontinued should be picked up by the parent/legal guardian. All medications should be picked up at the end of each school year. Parental/legal guardian notifications should be sent home at these times. When medications are not picked up after parent/legal guardian notification, they should be destroyed and that process should be witnessed and documented. Resources include: 20

22 Guidance for Disposal of Medications and Controlled Substances can be found at For federal guidelines about proper medication disposal go to: The FDA website has information on how to dispose of unused medications gmedicinesafely/understandingover-the-countermedicines/ucm pdf Q. Disposal of Needles and Syringes Needles and syringes should be disposed of in a manner consistent with appropriate Occupational Safety & Health Administration (OSHA) guidelines and district policy. For more information, go to id=10051 R. Emergency Building Evacuation and Medications Every health office should be supplied with a readily accessible, easily carried, and recognizable emergency bag/pack that includes supplies for basic first aid, and a glucose source. A list of all students with significant medical conditions and current medication histories as well as emergency contact numbers, should also be kept in the emergency bag/pack. S. Field Trips Medications that must be administered on field trips should be placed in a waterproof pill bag and labeled clearly with student name and birth date, medication, dose, route and time for administration by the licensed professional registered nurse. Resealable pill bags (1.5 x 2 inches) are available from most school health catalogs or a pharmacy supply store. If not administered by the school nurse, the person to whom field trip medication administration is delegated must be identified and appropriate training and demonstration of competency demonstrated and documented. The UAP will assume responsibility for safe transport and storage, as well as administration of medication. The disposition of the medication dose for field trips should be clearly documented on the student s medication record indicating to whom administration was delegated and time of actual administration. 21

23 T. Poison Control Center The Poison Control Center hotline ( ) can be called from anywhere in the state of Kansas and throughout the Kansas City metropolitan area 24/7. This connects callers directly to the Kansas Poison Control Center at Kansas University Medical Center (KUMC) for questions or concerns about medications, side effects, and pill/capsule identification. For more information, go to U. Research Medications in the School Setting School nurses may be confronted with requests to administer or monitor effects of experimental or off-label medications, or medication dosages outside the normal dosing range being used in clinical trials with participating students. Before such medications are administered, the licensed professional registered nurse will need to check school district policy related to experimental or off-label medications and should have all necessary information about the product to support safe administration at school. Requests to administer experimental and off-label medications, or dosages outside the normal range at school should be evaluated on a case-by-case basis by the licensed professional registered nurse and the prescribing primary care provider or specialist and be accompanied by written protocol or study summaries, consent forms, names and numbers of investigators or research teams, and published anecdotal and manufacturers reports. The licensed professional registered nurse effectively becomes part of the research/care team in these instances. He/she needs to be fully informed as to the intent of the study or off-label use of medications and have full access to current medical journals and pediatric medical or mental health facilities, as well as to prescribing providers and/or the research team. The NASN position statement on Research Medications in the School Setting (Experimental and Off-Label Medications in the School Setting) can be found at VI. STOCK EPINEPHRINE IN THE SCHOOL SETTING FOR TREATMENT OF UNDIAGNOSED SEVERE ALLERGIC REACTIONS / ANAPHYLAXIS BY SCHOOL PERSONNEL In April 2009, Substitute for HB 2008 was signed into law. K.S.A , K.S.A , and K.S.A b authorize any person to administer epinephrine in emergency situations to a student or a member of a school staff. (See Appendix J) This legislation exempts from liability for civil damages and from the practice of the healing arts any person who gratuitously and in good faith renders emergency care or treatment through the administration of epinephrine to a student or a member of a school staff at school, on school property or at a school sponsored 22

24 event if the person acts as an ordinary and reasonably prudent person would have acted under the same or similar circumstances. This legislation became effective upon its publication in the Kansas Statute Book July 1, A school may not maintain an epinephrine kit unless the school has consulted with a pharmacist licensed by the state board of pharmacy. The consultant pharmacist shall have supervisory responsibility for maintaining the epinephrine kit. The consultant pharmacist shall be responsible for developing procedures, proper control and accountability for the epinephrine kit. Periodic physical inventory of the epinephrine kit shall be required. An epinephrine kit shall be maintained under the control of the consultant pharmacist. This legislation authorizes any person to administer epinephrine in emergency situations to a student or a member of a school staff when: (1) the person administering the epinephrine reasonably believes that the student or staff member is exhibiting the signs and symptoms of an anaphylactic reaction; (2) a physician has authorized, in writing, the school to maintain a stock supply of epinephrine; and (3) the epinephrine is administered at school, on school property or at a schoolsponsored event. K.S.A , K.S.A , and K.S.A b do not address the role of the professional registered nurse in the school setting as it relates to this legislation. In June 2008, prior to the passage of HB 2008, the Kansas State Board of Nursing provided a ruling on stock epinephrine use by professional registered nurses. (See Appendix J: Statutes Pertaining to Epinephrine Kits.) K. S.A. 65-1,113 of the Kansas Nurse Practice Act authorizes the nurse to make a nursing diagnosis (distinct from a medical diagnosis) and to execute a medical regimen as prescribed by someone licensed to practice medicine and surgery (carry out a physician s order). Identifying and labeling anaphylaxis requires medical judgment and a medical diagnosis. Nurses are not authorized to make a medical diagnosis. Prescribing and administering a prescription drug (epinephrine) is at its root the practice of medicine. A physician can assign or delegate that medical act of administration to someone qualified by licensure. A qualified nurse can carry out that order. A nurse on his/her own may not make those choices because statute prohibits this. Currently in Kansas the law is not broad enough to allow a nurse to stock epinephrine, diagnose anaphylaxis and prescribe and use the stock epinephrine independently of a physician. To view K.S.A of the Kansas Nurse Practice Act, go to 23

25 Additional resources for School Health Services can be found at References American Academy of Pediatrics (AAP). Health in child care: A manual for health professionals. Author: Elk Grove Village, IL. Johnson, P.E., Hayes, J.M., Reinstein, V.F., Simmons, S.M., & Benson, J. (2003). Medication use in schools. Tallahassee: Florida Society of Health-System Pharmacists. Retrieved December 31, 2009, from Schwab, N.C. & Gelfman, M.H.B. (2001). Legal issues in school health services. Sunrise River Press: North Branch, MN. Selekman, J. (Editor). (2006). School nursing: A comprehensive text. F.A. Davis Company: Philadelphia. 24

26 VII. APPENDIX A. Delegation of Specific Nursing Tasks in the School Setting for Kansas Grid B. Sample Documentation of Instruction from the Licensed Professional Registered Nurse to Unlicensed Assistive Personnel C. Sample Authorization for Medication / Procedure to be Administered at School & Field Trips D. Samples Documentation of Medication Administration Forms E. Statute K.S.A Policies to allow student to self-administer certain medications. F. Sample Authorization for Self Medication: Emergency Asthma/Allergy Medications G. Sample Controlled Substance Log H. Sample Medication Error / Occurrence Report Form and Suggested Procedures for Medication Errors I. Sample Medication Count Log J. Statutes Pertaining to Epinephrine Kits a. K.S.A Epinephrine kits; requirements. b. K.S.A Epinephrine kits in schools; rules and regulations. c. K.S.A b Same; administration of epinephrine; limitation of liability. K. Kansas State Board of Nursing Ruling: The use of Epinephrine to treat lifethreatening emergencies in children not previously diagnosed. June L. Five Rights of Medication Administration in the School Setting M. Samples School Board Medication Policy 25

27 Appendix A Delegation of Specific Nursing Tasks in the School Setting for Kansas Grid 26

28 Delegation of Specific Nursing Tasks in the School Setting for Kansas (See K.A.R through 104) The following table is to be used to determine to whom Specialized Caretaking tasks or procedures may be delegated. Only the Registered Professional Nurse (RN) responsible for the student s nursing care may determine which nursing tasks may be delegated to an Unlicensed Assistive Person (UAP). The RN or the Licensed Practical Nurse (LPN) shall supervise all nursing tasks delegated in accordance with the criteria listed in KAR through104. Depending on parental permission and the age and maturity level of the child, many tasks may be performed by the child with oversight by the RN or LPN. Basic Caretaking tasks (including bathing, dressing, grooming, routine dental, hair and skin care, preparation of food for an oral feeding, exercise [excluding OT and PT], toileting and diapering, hand washing, transferring, and ambulation) may be performed by a UAP with supervision of an RN or LPN. After assessment and consideration of the principles of delegation, the decision to delegate nursing care must be based on the following: 1. The nursing task involves no nursing judgment. Judgment involves substantial specialized knowledge derived from biological, behavioral and physical sciences applied to decisions. 2. The UAP skills and competency levels. 3. The supervision criteria in KSA are evaluated and met. A = Allowed within Scope of Practice S = Within Scope of Practice with Supervision D = Delegated task with RN or LPN supervision X = Cannot perform Specialized Caretaking Prescription Medications: Oral, topical, inhalers, nebulizer and rectal Provider Order Required RN LPN UAP Provider = Person w/legal authority to prescribe (e.g. MD, DO, DDS, and ARNP or PA with protocol authority) RN and LPN = Licensed health professionals regulated by Kansas Nurse Practice Act UAP = All other school employees assisting with health services not licensed as a RN or LPN RN Scope of Practice: The delivery of health care services which require assessment, nursing diagnosis, planning, intervention & evaluation. LPN Scope of Practice: The delivery of health care services which are performed under the direction of the RN, licensed physician, or licensed dentist, including observation, intervention, and evaluation. Self administration: As agreed between RN or LPN and parent/legal guardian/provider. Self administration Yes A S D* A *If does not require dosage calculation and nursing care plan denotes route. Prescription Medications: Intramuscular Yes A S# X# A # No, unless an emergency medication as specified per an emergency action plan. Prescription Medications: Through tubes Yes A S X+ A +Except a feeding tube inserted directly into the abdomen inserted into the body Prescription Medications: Intermittent Yes A S X A Positive Pressure Breathing Machines Prescription Medications: Intravenous Yes A S** X A **According to LPN IV therapy law Over the Counter Medications * A A A A *Individual district policy may vary in requirements and limitations. Diabetes Care: Blood glucose Yes A S D A monitoring and/or carbohydrate counting and/or subcutaneous insulin administration Catheterization Yes A S D A Ostomy Care Yes A S D A Gastrostomy tube feedings: preparation Yes A S D A and/or administration Care of skin with damaged integrity Yes A A/S D A Care of skin with potential for damage No A S D A Tracheostomy: Care of ostomy, trach Yes A A/S D A and/or suctioning Measuring Vital Signs No A S D A Development of Individualized Health No A X X X Care Plan & EAP (Emergency Action Plan) The above document was developed in collaboration with the Kansas State Board of Nursing (KSBN) and the Kansas School Nurse Organization (KSNO). Approved by the KSBN Practice Committee on September 15,

29 Appendix B Sample Documentation of Instruction from the Licensed Professional Registered Nurse to Unlicensed Assistive Personnel 28

30 SAMPLE DOCUMENTATION OF INSTRUCTION AND SUPERVISION FROM THE REGISTERED NURSE (RN) TO UNLICENSED ASSISTIVE PERSONNEL (UAP) IN THE SCHOOL School Year Instructions: This form should be completed for each delegated nursing task to unlicensed assistive personnel. The completed form should be maintained in a central school office file whenever any nursing instruction, delegation and supervision of nursing tasks to unlicensed assistive personnel (UAP) in the school occur. The undersigned non-nursing school personnel have been instructed in and have (Identify Nursing Tasks) satisfactorily demonstrated the ability to carry out the identified nursing task(s). Both the registered nurse and the unlicensed person agree that the task(s) can be safely delegated and carried out by the unlicensed person designated below. Direct supervision / observation of the delegated task must be done at least twice during the academic year in a joint evaluation with the UAP in accordance with the requirements of K.A.R Periodic supervision beyond the two required supervisions is at the discretion of the registered nurse (RN) (Signature of UAP) Initials (Signature of RN Providing Instruction) Initials (Date of Initial Instruction) DOCUMENTATION OF SUPERVISION BY THE REGISTERED NURSE (RN) TO NON-NURSING UNLICENSED ASSISTIVE PERSONNEL (UAP) Dates of Supervision Initials of Both Parties Comments Adapted from Guidelines for Serving Students with Special Health Care Needs Part 2, June

31 Appendix C Sample of Authorization for Medication / Procedure to be administered at School and Field Trips 30

32 SAMPLE AUTHORIZATION FOR MEDICATION / PROCEDURE TO BE ADMINISTERED AT SCHOOL & FIELD TRIPS Part A Parent/Legal Guardian to Complete Name of Student: Date of Birth: Grade/Teacher: I grant permission for the school nurse or a delegated staff member to administer medication/treatment to my child at school as indicated by my child s physician accordingly below. I understand that I must provide any prescribed medication in its original labeled container. I also acknowledge the need and give permission for appropriate communications between the school health professional and the medical prescriber related to the specific treatment in question, including communication concerning: 1. the prescription or treatment itself (e.g., questions regarding dosage, method of administration, potential drug interactions, size of catheter for emergency insertion in the track of a dislodged gastrostomy tube); 2. implementation of the treatment in school (e.g., questions regarding safety concerns, infection control issues, or modifications in the treatment order related to the school setting or student's academic schedule); 3. student outcomes from the treatment (e.g., questions regarding observed side effects, possible untoward reactions, observations of behavior changes in the classroom); 4. and other pertinent issues related to the student s diagnosis, condition, or treatment. Parent/Legal Guardian Signature Parent/Legal Guardian (Printed Name) Today s Date Part B Physician to Complete Current Diagnosis(es): PHYSICIAN MEDICATION AND/OR TREATMENT ORDERS: (please specify) Medication / Treatment Dosage Time / Frequency Special Instructions: Physician Signature Physician (Printed Name) Today s Date Physician Phone Number Form Adapted from Olathe Unified School District /09 31

33 Appendix D Samples of Documentation of Medication Administration Forms 32

34 Front of Medication Form SAMPLE DAILY MEDICATION DOCUMENTATION RECORD School Year Student Name DOB School Grade Parent/Legal Guardian Name H # W # C# Delegation training completed by including how to perform the task/treatment, review of the AHCP (if applicable), with satisfactory return demonstration to the following listed UAP s. Initial each entry. Medication must be given within 30 minutes of prescribed time. Nurse / Staff Signature Initials Nurse / Staff Signature Initials Nurse / Staff Signature Initials Nurse / Staff Signature Initials Use the following key: ~ = No School Name / Purpose for Medication: R = Student Refused (notify parent/legal guardian) X = Student Absent A = Student at Activity Month Medication Strength Dose Hour [ ] Bottle home Parent Called Y N [ ] Bottle home Parent Called Y N [ ] Bottle home Parent Called Y N [ ] Bottle home Parent Called Y N [ ] Bottle home Parent Called Y N [ ] Bottle home Parent Called Y N 33

35 Back of Medication Form SAMPLE DAILY MEDICATION DOCUMENTATION RECORD School Year Student Name DOB Grade Parent/Legal Guardian Name H # W # C# Use the following key: ~ = No School Name / Purpose for Medication: R = Student Refused (notify parent/legal guardian) X = Student Absent A = Student at Activity Month Medication Strength Dose Hour Date Medication Name Possible Side Effects to Observe For Are Actions that promote a safe procedure are: Right Student, right medication, right dose, right time, and right route. A signed physician order and a signed parent/legal guardian request is required. Medications must be brought into the Health Office in the original container / prescription-labeled container. 34

36 Appendix E Statute K.S.A Policies to allow student to self-administer certain medications 35

37 SELF-ADMINISTER CERTAIN MEDICATIONS Chapter 72.--SCHOOLS Article 82.--ORGANIZATION, POWERS AND FINANCES OF BOARDS OF EDUCATION Policies to allow student to self-administer certain medications. (a) As used in this section: (1) "Medication" means a medicine prescribed by a health care provider for the treatment of anaphylaxis or asthma including, but not limited to, any medicine defined in section 201 of the federal food, drug and cosmetic act, inhaled bronchodilators and auto-injectible epinephrine. (2) "Health care provider" means: (A) A physician licensed to practice medicine and surgery; (B) an advanced registered nurse practitioner issued a certificate of qualification pursuant to K.S.A , and amendments thereto, who has authority to prescribe drugs as provided by K.S.A , and amendments thereto; or (C) a physician assistant licensed pursuant to the physician assistant licensure act who has authority to prescribe drugs pursuant to a written protocol with a responsible physician under K.S.A a08, and amendments thereto. (3) "School" means any public or accredited nonpublic school. (4) "Self-administration" means a student's discretionary use of such student's medication pursuant to a prescription or written direction from a health care provider. (b) Each school district shall adopt a policy authorizing the self-administration of medication by students enrolled in kindergarten or any of the grades 1 through 12. A student shall meet all requirements of a policy adopted pursuant to this subsection. Such policy shall include: (1) A requirement of a written statement from the student's health care provider stating the name and purpose of the medication; the prescribed dosage; the time the medication is to be regularly administered, and any additional special circumstances under which the medication is to be administered; and the length of time for which the medication is prescribed; (2) a requirement that the student has demonstrated to the health care provider or such provider's designee and the school nurse or such nurse's designee the skill level necessary to use the medication and any device that is necessary to administer such medication as prescribed. If there is no school nurse, the school shall designate a person for the purposes of this subsection; (3) a requirement that the health care provider has prepared a written treatment plan for managing asthma or anaphylaxis episodes of the student and for medication use by the student during school hours; (4) a requirement that the student's parent/legal guardian has completed and submitted to the school any written documentation required by the school, including the treatment plan prepared as required by paragraph (3) and documents related to liability; 36

38 (5) a requirement that all teachers responsible for the student's supervision shall be notified that permission to carry medications and self-medicate has been granted; and (6) any other requirement imposed by the school district pursuant to this section and subsection (e) of K.S.A , and amendments thereto. (c) A school district shall require annual renewal of parental/legal guardian authorization for the self-administration of medication. (d) A school district, and its officers, employees and agents, which authorizes the selfadministration of medication in compliance with the provisions of this section shall not be held liable in any action for damage, injury or death resulting directly or indirectly from the selfadministration of medication. (e) A school district shall provide written notification to the parent/legal guardian of a student that the school district and its officers, employees and agents are not liable for damage, injury or death resulting directly or indirectly from the self-administration of medication. The parent/legal guardian of the student shall sign a statement acknowledging that the school district and its officers, employees or agents incur no liability for damage, injury or death resulting directly or indirectly from the self-administration of medication and agreeing to release, indemnify and hold the school and its officers, employees and agents, harmless from and against any claims relating to the self-administration of such medication. (f) A school district shall require that any back-up medication provided by the student's parent/legal guardian be kept at the student's school in a location to which the student has immediate access in the event of an asthma or anaphylaxis emergency. (g) A school district shall require that information described in paragraphs (3) and (4) of subsection (b) be kept on file at the student's school in a location easily accessible in the event of an asthma or anaphylaxis emergency. (h) An authorization granted pursuant to subsection (b) shall allow a student to possess and use such student's medication at any place where a student is subject to the jurisdiction or supervision of the school district or its officers, employees or agents. (i) A board of education may adopt a policy pursuant to subsection (e) of K.S.A , and amendments thereto, which: (1) Imposes requirements relating to the self-administration of medication which are in addition to those required by this section; and (2) Establishes a procedure for, and the conditions under which, the authorization for the self-administration of medication may be revoked. History: L. 2004, ch. 124, 5; L. 2005, ch. 136, 1; July 1. 37

39 Appendix F Sample Authorization for Self Medication: Emergency Asthma/Allergy Medications 38

40 SAMPLE EMERGENCY ASTHMA/ALLERGY MEDICATIONS PART A: Parent/Legal Guardian to Complete for students K-12 Name of Student: Date of Birth: School: Grade: The above student has been instructed on self-administration of medication, and I hereby give my permission for him/her to administer at school as ordered the medication(s) listed below. I understand that it is my responsibility to furnish this medication. I acknowledge that the school incurs no liability for any injury resulting from the selfadministration of medication and agree to indemnify and hold the school, and its employees and agents, harmless against any claims relating to the self-administration of such medication. I also acknowledge the need and give permission for appropriate communications between the school health professional and the medical prescriber related to the specific treatment in question, including communication concerning: 1. the prescription or treatment itself (e.g., questions regarding dosage, method of administration, potential drug interactions, size of catheter for emergency insertion in the track of a dislodged gastrostomy tube); 2. implementation of the treatment in school (e.g., questions regarding safety concerns, infection control issues, or modifications in the treatment order related to the school setting or student's academic schedule); 3. student outcomes from the treatment (e.g., questions regarding observed side effects, possible untoward reactions, observations of behavior changes in the classroom); 4. and other pertinent issues related to the student s diagnosis, condition, or treatment. Parent/Legal Guardian Signature Parent/Legal Guardian (Printed Name) Today s Date PART B: Physician to Complete Medication Purpose Dosage Time / Frequency Conditions & Special Circumstances for use: Length of time medication is to be administered: Physician Signature Physician (Printed Name) Today s Date Physician Phone Number PART C: School Nurse to Complete School Nurse Review of order and procedure with the student. Completed Date of Review RETURN TO SCHOOL NURSE Form Adapted from Olathe Unified School District /09 39

41 Appendix G Sample Controlled Substance Log 40

42 SAMPLE CONTROLLED SUBSTANCE LOG USD School Name Student Name: School Year: School: DATE Medication/Mg # Rec d # Wasted # Returned Witness1 Witness 2 Notes: Form Adapted from Olathe Unified School District /09 41

43 Appendix H Suggested Procedures for Medication Errors Sample Medication Error / Occurrence Report Form 42

44 SUGGESTED PROCEDURES FOR MEDICATION ERRORS As soon as an error in the administration of medication is recognized, initiate the following steps: 1. Overdose or Administration of Incorrect Medication or Administration of Medication to the Wrong Student a. Keep the student in the health room. If student has already returned to class when the error is determined, have student accompanied to the health room. b. Assess student s status. c. Identify the incorrect dose or type of medication taken by the student. d. Notify parents/legal guardians. e. Notify principal. f. Notify health care provider. g. If unable to contact the health care provider, contact the Poison Control center at for instructions. Give the name and dose of the medication taken in error. Give the age and approximate weight of the student. Give the name(s), dose(s), and time of last does of other medication being taken by student. h. Follow the instructions from the Poison Control Center. If unable to complete their directions, explain the problem(s) to the Poison Control Center and student s status. i. Carefully record in ink (in the student s health record and the medication log) all circumstances and actions taken, including instructions from the Poison Control Center and student s status. j. Submit a written report within 48 hours on the Medication Error Report Form, including the name of the student, the parent/legal guardian name and phone number, and a specific statement of what the medication error was, who was notified, and what remedial actions were taken. Send a copy of the form to the school nurse coordinator or designated school administrator. 2. Missed Dose or Under Dosage a. Identify student who took the incorrect dosage. b. Notify parent/legal guardian. c. Notify principal. d. Contact the health care provider to determine if the remainder of the dose should be omitted or administered. e. Carefully record in ink all circumstances and actions taken on the student s health record and on the medication form. Fill out Medication Incident Report. 43

45 3. Missed Dose One attempt must be made to notify student if student does not respond, document on back of medication log and notify parent/legal guardian. 44

46 USD Health Services SAMPLE I MEDICATION INCIDENT / OCCURRENCE REPORT A medication incident (error) is defined as failure to administer the prescribed medication to the right student, at the right time, the right medication, the right dose or the right route. The person who administered the medication should complete this form. Student Name: Date of Birth: Grade: School: Date of Report: Time: a.m./p.m. Date and Time of Incident (Error): Name of person observing medication: Name of medication and dosage prescribed: Describe circumstances leading to incident (use reverse side if necessary): Action Taken: Health Services Director Notified: Yes No Parent/Legal Guardian Notified: Yes No Building Administrator Notified: Yes No Licensed Prescriber Notified: Yes No Poison Control Notified (If Applicable): Yes No Date Notified: (month/day/year) Date Notified: (month/day/year) Date Notified: (month/day/year) Date Notified: (month/day/year) Date Notified: (month/day/year) Time notified: AM PM Time notified: AM PM Time notified: AM PM Time notified: AM PM Time notified: AM PM Describe Outcome (use reverse side if necessary): Copy of this form placed into student health folder: Yes No Original form sent to district risk manager / administrator? Yes No Signature of Person Completing Form Date This incident report form is intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected by law. Disclosure of confidential information is prohibited. Adapted from Seaman Unified School District /09 45

47 SAMPLE II REPORT OF MEDICATION ERROR Name of School Name of Student Date and Time of Error Birth Date Name and Position of Person Administering Medication Prescribed Medication / Dosage / Route / Time Describe error and circumstances leading to error: Describe action taken: Persons notified of error: Principal Role Name Date Time Parent/Legal Guardian Physician School Health Coordinator Phone Other Signature (person completing Date Follow-up information if applicable (to be completed by School Health Coordinator): Original: School Health Coordinator Copy: Principal 46

48 Appendix I Sample Medication Count Log 47

49 SAMPLE MEDICATION COUNT LOG Student Medication School Year Date New Supply Count On Hand Count # Dispensed since last count Signature #1 Signature #2 Form adapted from Jefferson County Health Department 03/10 G:\schoolnurse\schools\MEDICATION COUNT LOG.doc 48

50 Appendix J Statutes Pertaining to Epinephrine Kits a. K.S.A Epinephrine kits; requirements. b. K.S.A Epinephrine kits in schools; rules and regulations. c. K.S.A b Same; administration of epinephrine; limitation of liability. 49

51 STATUTES PERTAINING TO EPINEPHRINE KITS Chapter 72.--SCHOOLS Article 82.--ORGANIZATION, POWERS AND FINANCES OF BOARDS OF EDUCATION Epinephrine kits; requirements. Any accredited school may maintain an epinephrine kit. An epinephrine kit may consist of one or more doses of epinephrine. Epinephrine from an epinephrine kit shall be used only in emergency situations when the person administering the epinephrine reasonably believes that the signs and symptoms of an anaphylactic reaction are occurring and if administered at school, on school property or at a school-sponsored event. A school may not maintain an epinephrine kit unless the school has consulted with a pharmacist licensed by the state board of pharmacy. The consultant pharmacist shall have supervisory responsibility for maintaining the epinephrine kit. The consultant pharmacist shall be responsible for developing procedures, proper control and accountability for the epinephrine kit. Periodic physical inventory of the epinephrine kit shall be required. An epinephrine kit shall be maintained under the control of the consultant pharmacist. History: L. 2009, ch. 102, 2; July Chapter 65.--PUBLIC HEALTH Article 16.--REGULATION OF PHARMACISTS Epinephrine kits in schools; rules and regulations. The state board of pharmacy may adopt any rules and regulations which the board deems necessary in relation to the maintenance of epinephrine kits under K.S.A Supp , and amendments thereto. History: L. 2009, ch. 102, 3; July b Chapter 65.--PUBLIC HEALTH Article 28.--HEALING ARTS b. Same; administration of epinephrine; limitation of liability. (a) The practice of the healing arts shall not be construed to include any person administering epinephrine in emergency situations to a student or a member of a school staff if: (1) The person administering the epinephrine reasonably believes that the student or staff member is exhibiting the signs and symptoms of an anaphylactic reaction; (2) a physician has authorized, in writing, the school to maintain a stock supply of epinephrine; and (3) the epinephrine is administered at school, on school property or at a school-sponsored event. (b) Any person who gratuitously and in good faith renders emergency care or treatment through the administration of epinephrine to a student or a member of a school staff at school, on school property or at a school-sponsored event shall not be held liable for any civil 50

52 damages as a result of such care or administration or as a result of any act or failure to act in providing or arranging further medical treatment where the person acts as an ordinary reasonably prudent person would have acted under the same or similar circumstances. History: L. 2009, ch. 102, 1; July 1. 51

53 Appendix K Kansas State Board of Nursing Ruling: The use of Epinephrine to treat life-threatening emergencies in children not previously diagnosed. June

54

55

56 Appendix L Five Rights of Medication Administration in the School Setting 55

57 FIVE RIGHTS OF MEDICATION ADMINISTRATION IN THE SCHOOL SETTING Important safety checks will help to assure safe medication administration in the school setting. Safety checks (AAP, 2005, p. 493) include: Medication is in a child resistant container. The presence of the original prescription label or over the counter medication manufacturer s label with the name and strength of the medication and physician s directions for use (phone or written). Name of child on container is correct for both first and last names. Current date on prescription / expiration label covers period when medication is to be given. Name and phone number of licensed health professional who ordered medication is on the container or on file. Instructions are clear for dose, route, and time to give medication. Medication errors will be controlled by checking the following 5 items each time medication is given (AAP, 2005, p. 494). 1. The right child / student a. Confirm that the student to receive the medication is the correct student. b. Ask name if student unknown to you. c. If non-verbal, confirm identify with teacher or paraprofessional 2. The right medication / drug Confirm that the medication to be given is the medication order by the primary care provider or specialist is the medication the parents/legal guardians have given permission to be administered at school and is the medication in the prescription labeled bottle or over-the-counter manufacturer labeled container. (See Authorization for Medication / Procedure to be Administered at School & Field Trips) 3. The right dose Confirm the amount of medication prescribed (for example, 1 Tablet), is the dose of medication given to the student. 4. The right time Confirm that the student is getting the medication at the time prescribed. NOTE: The licensed professional registered nurse may reasonably work within a timeframe or window of minutes of the prescribed time for medication administration based on priorities and nursing 56

58 judgment without creating an error of omission. Any window of time granted to UAPs to whom medication administration has been delegated should be clearly documented in the delegation plan of care by the supervising licensed professional registered nurse. 5. The right route of administration Confirm that medication orally is given orally. NOTE: when drops are prescribed, it s essential that eye drops are administered in the eyes, ear drops are administered in the ears, and nasal drops / sprays are administered in the nose. See Medication Errors (p. 19) in Guidelines for Medication Administration in Kansas Schools, 2010 for reporting of medication errors. Reference American Academy of Pediatrics (AAP). Health in child care: a manual for health professionals. Author: Elk Grove Village, IL. 57

59 Appendix M Samples School Board Medication Policy 58

60 BOARD POLICY: SAMPLE I DISTRICT MEDICATION POLICY The supervision of medications shall be in strict compliance with the rules and regulations of the board as carried out by district administrators. K.S.A ADMINISTRATIVE PROCEDURE: 1. A student is eligible to take medication at school if it is to be given at a specific time of day during regular school hours or if it is to be given more than three times a day. Unnecessary medication administration at school is strongly discouraged. 2. Administration of acetaminophen or ibuprofen requires parent/legal guardian authorization (See 5). 3. Both parent/legal guardian authorization and a written order from a person licensed to practice medicine or dentistry in the State of Kansas or other competent jurisdiction are required for administration of all medications in the school setting with the exception of situations addressed in #5. The physician order must be updated at the beginning of each school year and dated not prior to May 1 of the previous school year. a. The order should include the following: 1. Name of student 2. Diagnosis/reason for medication 3. Name of medication to be given 4. Dosage to be given (A new physician written order will be required for dosage changes.) 5. Times to be given 6. Method of administration 7. Expected duration of treatment b. Lawful custodians are responsible for: 1. Verbalizing request for medication administration to school nurse 2. Obtaining physician or dentist order 3. Supplying medication in the original container 59

61 4. Authorizing school health services personnel to exchange information with the attending physician and personnel from the dispensing pharmacy. c. The school nurse is responsible for: 1. Keeping medications locked in specially designed cabinet and/or small locked container for refrigeration. 2. Counting all regulated medications when received, weekly thereafter, and verifying with at least one other adult (lawful custodian or school employee). 3. Initiating a medication order, 4. Instructing unlicensed school personnel who have been identified as necessary to implement the administration plan and documenting training and supervision according to the delegation regulations of the Kansas State Board of Nursing. d. Termination 5. Observing students for desired and potential effects. 6. Completion of required medication documentation. 7. Providing necessary feedback to lawful custodian and physician. 1. Short-term medication: The medication plan will be terminated when medication supplied by the lawful custodian has been administered. 2. Long-term mediation/prn (as needed): During the school year the termination of a medication plan by the lawful custodian, prescribing physician, or school must be by written or verbal notice. On July 31, at the end of the extended school year all medication orders will terminate. 4. Self-Administration: a. The self-administration of medicine for the treatment of anaphylactic reactions or asthma is allowed for students in grades K-12. To be eligible, a student shall meet all requirements of this policy. Parents/legal guardians shall submit a written statement from the student s health care provider stating: i. The name and purpose of the medication; ii. The prescribed dosage; iii. The conditions under which the medication is to be self-administered; 60

62 iv. Any additional special circumstances under which the medication is to be administered; and v. The length of time for which the medication is prescribed. b. The statement shall also show the student has been instructed on self-administration of the medication and is authorized to do so in school. c. An annual renewal of parental/legal guardian authorization for the self-administration of medication is required. d. The school district, and its employees and agents, which authorize the selfadministration of medication in compliance with the provisions of this policy, shall not be liable in any action for any injury resulting from the self-administration of medication, and written notification in this regard is provided to the parents/legal guardians. e. Parents/legal guardians shall sign the waiver of liability provided on the authorization for Self-Administration of Emergency Asthma/Allergy Medication form. 5. Health Room Stock of Acetaminophen and Ibuprofen a. Health rooms will stock tablet forms of acetaminophen and ibuprofen. b. Parents/legal guardians will provide annual written permission on district provided forms for the school nurse to administer the medication. c. Contact with the parents/legal guardians will be attempted by the school nurse prior to each administration of health room stock, over-the-counter medication to ensure continuity of care for the student before and after school. Form adapted from Olathe Unified School District /10 61

63 SAMPLE FORM II MEDICATION ADMINISTRATION POLICY When your child must have medication of any type (over-the-counter meds, inhalers, or daily meds) during school hours, you have the following choices: 1. You may discuss with your doctor an alternative schedule of medication administration so it can be given outside the school hours. 2. When the medication is prescribed for three times daily. Your child should given the medication before coming to school, after returning home from school, and before going to bed. 3. You may come to the school and administer the medication yourself. 4. You may get a Medication Administration Form from the school and have your physician indicate on the form the diagnosis, drug, dose, time to be given, along with the physician s signature. This form must be signed by the parent/legal guardian and brought to school prior to any medication being administered. The medication must be in a pharmacy-labeled manufacturer s container with the child s name clearly visible on the container. Students must take all medication in the presence of designated school personnel. 5. Exception: Medication may be self-administered by the student if the Administration of Medication Form states this and has been signed by the parent/legal guardian and the physician and is on file at the school. 6. In fairness to those giving the medications, and for the safety of your child, this policy must be followed strictly. We ask this, not to make things difficult for you, but to insure the health and well being of all students. 7. Remember, the only way medication can be given at school is with the Medication Administration Form filled out and signed by the physician and parent/legal guardian. The medication must also be in a properly labeled container. Form adapted from Ulysses Unified School District /10 62